First Name:
 Middle Name:
 Last Name:
Address:
 Email Address:
 Phone Number:

In the past 5 years have you ever been convicted of a crime, excluding misdemeanors and traffic violations?
(A conviction will not necessarily bar you from employment.) 		Yes
No
If YES, explain

Social Security Number:
Emergency Contact:
Name: Phone Number:

Job Applying:
 Starting Wage expection:
/Hr 		/Wk

Are you legally able to serve liquor?
If NO, Age: 		Yes No Are you legally able to work in the U.S.?
Yes No

Total hours available per week:

Date you can start: (mm/dd/yy) 		Available

From:

To: 		Mon


Tue


Wed


Thu


Fri


Sat


Sun


Name of school most recently attended:
Address:

Phone:

Name of second most recent school attended:
Address:

Phone:

Graduated: YES NO ATTENDING Grade Avg:
Areas of Specialization:
Please list two most recent work experiences, including military service and volunteer activities

Company: Location:
Dates worked: From: (mm/dd/yy)
To: (mm/dd/yy)
Position:
Supervisor:

Phone:

Reason for leaving: RA Use:

Company: Location:
Dates worked: From: (mm/dd/yy)
To: (mm/dd/yy)
Position:
Supervisor:

Phone:

Reason for leaving: RA Use:
Do you have now or have you had within the last six months any contagious or communicable diseases, or gastral intestinal infections which according to the law might prevent you from working as a food handler or server?
If YES to any of the above explain: YES NO

I certify that the information above is correct to the best of my knowledge and understand that any falsification, material omission or misrepresentation of the information may constitute grounds for dismissal. I authorize my former employers and other individuals to give the company information concerning me. If requested to do so, I agree to submit to a physical examination which I must successfully pass as a condition of being accepted for employment. If I become employed, I will be free to terminate my employment at any time for any reason and the company retains the same right. If I don’t hear from the company for four (4) weeks after my application date, I understand that I am not under consideration of possible employment anymore. I also understand that I have one week to inquire reason why I am not accepted for employment. During application procedure, if I feel I am unlawfully discriminated against or sexually harassed, I can contact Employee Relations (1-800-327-3369) immediately
Voluntary Information that does not affect your employment

Male: Female:
Job Applied: (mm/dd/yy)


Date: 		Are you Hispanic or Latino? Yes No Stop if you answered "yes."
Choose one of the following if you answered “No” to the above question:
White
Black or African
America
Native Hawaiian or
other Pacific Islander
 Asian
 American Indian
or Alaska Native
 Two or More
Races

         Select the location you are applying to:

                                 Where did you hear about us?